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Ultrasound lymphatic imaging for the diagnosis of metastatic central lymph nodes in papillary thyroid cancer

  • Ultrasound
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Abstract

Objectives

Up to 40% of papillary thyroid cancer (PTC) patients have lymph node metastasis, a condition that implies persistent, recurrent, or progressive disease. However, the American Joint Committee on Cancer Manual states that there is no reliable examination for adequate lymph node staging. Therefore, our aim is to develop a lymphatic imaging technique using ultrasonography to address this challenge.

Methods

We consecutively enrolled PTC patients who underwent ultrasound (US) lymphatic imaging via the peritumoral injection of contrast media. Identification of the sentinel lymph nodes and the targeted sentinel lymph nodes was separately based on the lymphatic drainage pathway and the enhancement patterns. Every identified targeted node was assigned a score, according to the features on conventional US and enhancement patterns, and was referred for ultrasound-guided fine-needle aspiration. Cytological and histopathologic results represented the statuses of the targeted lymph nodes and overall central lymph nodes, respectively, which were applied to evaluate the diagnostic performance of US lymphatic imaging.

Results

In total, 100 PTC patients were included. On the basis of the cytological results, the sensitivity (97.1%, 95% confidence interval [CI]: 84.7–99.9%) of detecting positive targeted nodes by US lymphatic imaging significantly increased by 45.5% at a threshold of 4 or higher (p = 0.0001), without loss of specificity (p = 1.0000). The surgical results showed that the metastatic degree was positively correlated with an increase in the score (τ: 0.671, p < 0.001).

Conclusion

Ultrasound lymphatic imaging has a high diagnostic performance, and its corresponding scoring system facilitates grading of the nodal burden in the central compartment.

Key Points

• Ultrasound neck lymphatic imaging is an effective contrast-enhanced ultrasound (CEUS) technique (applied after the peritumoral injection of contrast media) for identifying sentinel lymph nodes in the central compartment by tracing the imaged afferent lymphatic vessel.

• Lack of enhancement or perfusion defects is the typical enhancement pattern for recognizing the involved central lymph nodes.

• Ultrasound lymphatic imaging for identification of positive central lymph nodes before surgery may effectively avoid complications associated with the surgical sentinel node procedure.

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Abbreviations

AJCC:

American Joint Committee on Cancer

AUC:

Area under the curve

CEUS:

Contrast-enhanced ultrasound

CI:

Confidence interval

CLNM:

Central lymph node metastasis

cN0:

Clinically negative lymph nodes

cN1:

Clinically positive lymph nodes

FNAC:

Fine-needle aspiration cytology

NCDB:

National Cancer Database

NPV:

Negative predictive value

pCCND:

Prophylactic central lymph node dissection

PPV:

Positive predictive value

PTC:

Papillary thyroid cancer

ROC:

Receiver operating characteristic

SEER Program:

Surveillance, Epidemiology, and End Results Program

US:

Ultrasound

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Acknowledgments

The authors are grateful to the support from prof. Weiwei Zhan, Ruijin Hospital Ethics Committee and the financial support from the National Natural Science Foundation of China (No. 81671688, 81801699), Doctoral Innovation Foundation of Shanghai Jiao Tong University School of Medicine (BXJ201916), and Shanghai Municipal Health and Family Planning Commission (20174Y0069).

Funding

This study has received funding from the National Natural Science Foundation of China (No. 81671688, 81801699), Doctoral Innovation Foundation of Shanghai Jiao Tong University School of Medicine (BXJ201916), and Shanghai Municipal Health and Family Planning Commission (20174Y0069).

Author information

Author notes

  1. Zhenhua Liu and Ronghui Wang should be considered joint first authors due to their equal contribution to this work.

Authors and Affiliations

  1. Department of Ultrasound, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, 2nd Ruijin Road 197, Shanghai, 200025, People’s Republic of China

    Zhenhua Liu, Ronghui Wang, Jianqiao Zhou, Yijie Dong, Ting Luo, Xing Wang & Weiwei Zhan

  2. Department of Ultrasound, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Yishan Road 600, Shanghai, 200233, People’s Republic of China

    Yuanyi Zheng

Authors
  1. Zhenhua Liu
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Correspondence to Jianqiao Zhou or Weiwei Zhan.

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Guarantor

The scientific guarantor of this publication is Weiwei Zhan (Ruijin Hospital, Shanghai Jiao Tong University School of Medicine).

Conflict of interest

The authors of this manuscript declare no relationships with any companies.

Statistics and biometry

No complex statistical methods were necessary for this paper.

Informed consent

Written informed consent was obtained from all subjects (patients) in this study.

Ethical approval

The study was approved by the Ruijin Hospital Ethics Committee.

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• Diagnostic study

• Performed at one institution

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Weiwei Zhan and Jianqiao Zhou should be considered joint senior author

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Liu, Z., Wang, R., Zhou, J. et al. Ultrasound lymphatic imaging for the diagnosis of metastatic central lymph nodes in papillary thyroid cancer. Eur Radiol 31, 8458–8467 (2021). https://doi.org/10.1007/s00330-021-07958-y

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  • DOI: https://doi.org/10.1007/s00330-021-07958-y

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